Wednesday, December 19, 2012

No Longer Living in Denials

I received this notice, dated 1 March 2012, from our billing department after a denial for reimbursement following a successful right ventricular outflow tract ablation I performed:

"Paul Rossi DO, a Cigna Medical Director, reviewed Use of an intracardiac electrophysiological 3-dimensional mapping system in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient scientific evidence to support use and determined the service(s) is not a covered benefit as indicated below:

The use of an intracardiac electrophysiological 3- dimensional mapping system is considered medically necessary when used to guide supraventricular arrhthmias. Based upon current available information, coverage cannot be approved to support the use of intracardiac electrophysiological 3-dimensional mapping in the diagnosis, treatment, or management of ventricular arrhythmias or any other condition because there is insufficient evidence to support its use. At the present time, it is considered non-standard testing and falls under the category of experimental/investigational/unproven."

These denials are part of life for doctors - it's all part of the game. But the era of social media is upon us, and with it, revenge.

The CARTO® EP Navigation System (Biosense Webster, Inc., Diamond Bar, CA) received 510(k) premarket approval in December 1999 by the U.S. Food and Drug Administration (FDA) as a Class II device for catheter-based cardiac mapping (FDA, 1999). The FDA indications for use state the intended use of the CARTO EP Navigation System is catheter-based cardiac mapping. The CARTO EP Navigation System and accessories have had numerous enhancements with the latest device, the CARTO 3 Version 1.05 EP Navigation System and accessories, receiving 510(k) premarket approval in 2009 (FDA, 2009; FDA, 2006; FDA, 2000).

Hardly experimental.

Furthermore, those same recommendations detail at least 8 different studies where 3-dimensional mapping was used for VT ablation and include this statement from the Joint Heart Rhythm Society/American College of Cardiology guidelines for ablation (2006):

"Electroanatomic magnetic mapping capabilities are being applied to aid in the diagnosis and nonpharmacological treatment of arrhythmias. The authors state, 'although not yet established as requisite or "core" equipment for the EP laboratory, these and other emerging technologies have had, and will continue to have, a major impact on the practice of cardiac arrhythmia management.'"

I'm sorry, but I do not see the words "experimental" in Cigna's own documentation nor does their document suggest that appropriate standard of care for 3D mapping be reserved exclusively for "supraventricular" arrhythmias.

Welcome to the world of social media, Cigna. I can only hope that every employee out there with an option to choose insurers strongly consider picking another insurance carrier since they will be much better (and more safely) served when they need their ventricular tachycardia successfully ablated. Rest assured, my response to Dr. Rossi's coverage denial decision is forthcoming.

First, as a part-time employee at my healthcare-associated hospital, there are not other insurance options for employees and since I have three dependents, I really do have to have some sort of 'coverage' in case I'm the one with the need for the 3D mapping or whatever. Also, it's not just 'Cigna'. I'm sure that it's all of the insurance companies run by MBAs and economists, stock brokers, and financial investors without the health background. The only excellent insurance company I heard of was a company that probably cost an arm and a leg initially, and because my family or I weren't sick, didn't need to use it much at all.

Second, any person investigating these denials with the assistance of the commonsense and knowledge of the principled physician CAN tell these guys working for insurance companies are merely rubber-stamping something to satisfy their employers whose business it is to deny as much 'expensive' therapy as possible.

After I determined I was in the right to contest denial of continued hospitalization for an ill family member, I found that my ill family member's medical therapy had not stabilized while in-patient, and he had been insufficiently discharge as there were inadequate transitional and rehabilitation services in my community, as well as other treatment factors to counter the initial act of denying coverage for expensive hospital care. If this had been a matter where I could sue the insurance company and take care of my ill relative's needs at the same time, believe me I would have.

My biggest argument is that their initial denial resulted in severe morbidity symptoms three months later, and delayed recovery to long beyond the time if initial and proper rehab had been provided.

I wrote a long letter to the credentialing agency, a letter to the employer, and a letter to the co-worker insurance liaison.

The insurance company contract changed to another company at the end of the year, but it is my impression that the same strategy is employed by all insurers. Sometimes, it is as simple as the default means 'sign me up'. Other times the strategy is 'no' unless you threaten to send a lawyer. Sometimes the strategy is 'show me the cash, first'. Whatever. It's a ploy to get out of pushing the health industry to be more efficient, instead, satisfy the needs of the insurance company, first.

When a denial is received, it is reviewed and if all coding and procedural numbers cross-checked and confirmed, it is resubmitted for payment. If the payment is denied a second time and the issue cannot be resolved in the accounts receivable office, they are then brought to the attention of the doctor to assure there were not problems from our end. This process of denials and resubmissions can take months. Hence the delay in the Cigna letter being brought to my attention.

I once was on a jury probably 15 years ago with a woman who used to work for HandyAndy (the now defunct big box store)at their customer desk. She now worked for HMO Illinois approving claims, and she said: "They give me the rules and I apply them!" She had barely a high school education. I'll never forget my horror, especially since at that time that was my insurance! This is a sad story.

I saw this on MassDevice and apologize for not commenting sooner. Was great to read a kindred spirit's musings since this is what we do for a living (I've got a LOT of Dr. Rossi's denials!) Your post hopefully has led others to empower patients to appeal these unreasonable decisions and fight for the care they need. Continued success! Keep fighting! We will.

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.